Prevention of Future Deaths reports · 2019

Mark Anderson

Regulation 28 report to prevent future deaths, reference 2019-0435, written 17 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report17 Dec 2019
Reference2019-0435
DeceasedMark Anderson
CoronerSarah-Jane Richards
Coroner areaSouth Wales Central
CategoryRoad (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

ANNEX A 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

NOTE: This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

Mr. Paul Orders, The Chief Executive Cardiff Council; 

1 

CORONER 

I am Dr. Sarah-Jane Richards, HM Assistant Coroner, for the coroner area of South 
Wales Central. 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On  30  May  2019  an  inquest  was  opened  was  into  the  death  of  Mr.  Mark  Anthony 
Anderson  aged  22  who  had  died  at  Trelai  Park,  Cardiff  on  28  May  2019.  The 
circumstances  were  that  Mark  Andersen  together  with  other  motorcycling  friends  had 
met  at  Trelai  Park  to  ride  their  motorcycles  ‘off-road’.  This  was  a  common  venue  for 
such activities although the area was not designated for motorcycling but as an area for 
parents to be with their children, dog walkers and joggers.   

The deceased was not wearing any motorcycling clothing and witnesses state that the 
deceased  was  not  wearing  a  helmet.  Detective  Inspector 
  advised  that  the  area 
was  “well  known  for  off-road  biking”  and  what  might  have  been  a  “bumper  from  a 
scrambling–type motorcycle“ had been found at the scene. 

Persons present at the scene were reluctant to furnish the police with any details of what 
had  occurred  and  the  motorcycle  used  by  the  deceased  was  ‘spirited  away’  from  the 
scene. It has neither been traced nor examined by the police forensics team.  

, a member of the public who lived locally, was teaching her 8 year old 
son how to ride his peddle cycle in Trelai Park on the afternoon of the accident. She told 
the  inquest  that  her  attention  had  been  drawn  to  two  motorcyclists  one  of  whom  was 
doing  ‘wheelies’  around  the  park.    The  two  motorcycles  then  began  racing  each  other 
around the park very fast. Since they were in the vicinity of her son she called him to her 
for fear he could be injured and they then left the park. She was not surprised to hear 
that there had been a fatal accident involving the motorcyclists. 

She  stated  that  there  was  considerable  public  concern  about  the  safety  of  the  public 
especially  children  who  use  Trelai  Park  for  exercise  and  recreational  purposes  due  to 
the  presence  of  motorcyclists  who  use  the  park  for  ‘off  road’  activities.  She  thought 
complaints had been made to the Council about the danger posed to the public by such 
  stated  that  as  far  as  she  was 
activities  but  that  they  had  gone  unheeded.   
aware, the motorcycling his not regulated or confined to specific areas of the park and it 
was on the whole, young guys wanting to let of steam. Finally, while she accepted that 
that  ‘off  road’  motorcycling  was  an  activity  young  males  enjoyed  and  for  which  there 
should  be  some  accommodation  by  the  Council,  her  immediate  concern  was  for  the 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 safety of children and pedestrians.  

4 

CIRCUMSTANCES OF THE DEATH 

The tragedy occurred when motorcycles on the same narrow path traversing the park, 
travelling  in  opposite  directions  approached  each  other.    Each  swerved  to  avoid  the 
other but in doing so swerved into each other’s path. Mark Anderson suffered fatal head 
injuries. Life was declared extinct at the scene. The CoD provided at post mortem was:-  

1a. Anterior basal skull fracture with laceration of intracranial internal carotid arteries.  

Toxicology analyses of post-mortem blood and urine confirmed neither drugs nor alcohol 
had been consumed in the hours proximal to death. 

5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.   

The safety of the general public, in particular children and the elderly, is at risk while 
motorcyclists continue to use Trelai Park as an unfettered area for racing their 
motorcycles. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation have the power to take such action.  

1.  The prevention of Trelai Park being used as a venue for off-road motorcycling. 

2.  The provision of a designated area of ground in the vicinity where motorcyclists 
can ride their motorcycles and generally let of steam with minimal risks to 
themselves and avoiding any risk to the general public. 

3. 

In the event that an alternative area of ground cannot be identified for 
recreational use by young motorcyclists, for a portion of Trelai Park to be 
designated exclusively for the use of young motorcyclists with boundaries 
clearly defined. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 13 March 2020 allowing for the Michaelmas holiday. I, the Coroner, may 
extend the period upon request. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the family who may find it useful or of interest. 

Secretary of State for Wales; First Minister of Wales; Minister for Health and Social 
Services; The Chief Constable, South Wales Police; the Mother of the deceased; the 
member of the public who provided evidence at the Inquest. 

I am also under a duty to send the Chief Coroner 
response.  

 copy of your 

The Chief Coroner may publish either or both in a complete or redacted or summary 

2

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

17 December 2019 

SIGNED:                      

Dr. Sarah - Jane Richards, HM Assistant Coroner for South Wales Central 

3

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